This application seeks to conduct a large, pragmatic clinical trial demonstration project within the NIH Health Care Systems (HCS) Research Collaboratory. The Dialysis Research Network, comprised of academic investigators and dialysis provider organizations, is proposing the Time to Reduce Mortality in End-Stage Renal Disease (TiME) trial. The TiME trial is a large, cluster-randomized, pragmatic trial that will evaluate the effects on survival, hospitalizations, and health-related quality of life of a systemaic implementation of a hemodialysis session duration of at least four hours for individuals with irreversible kidney failure who are initiating treatment with maintenance hemodialysis. The trial will be conducted in approximately 320 dialysis facilities owned by the two largest dialysis provider organizations in the United States. The electronic data systems of the dialysis provider organizations will be used for identification of participating dialysis facilities, for collection f trial data and outcomes, and for transmission of data to the University of Pennsylvania Clinical Research Computing Unit which will serve as the data coordinating center for the trial. The project will be implemented in two phases: the UH2 planning phase and the UH3 implementation phase, each of which has specific milestones for progress and metrics for evaluating the innovative approaches used for the trial. The Dialysis Research Network application fulfills the objectives of the NIH HCS Research Collaboratory Pragmatic Clinical Trials Demonstration Projects program. The TiME trial is pragmatic: 1) it evaluates an intervention implemented in the usual care setting, 2) it utilizes data that are obtained for routie clinical care, 3) it has minimal restrictions on eligibility, and 4) it requires no specific expertse of practitioners. The outcomes are important both clinically and from the perspective of the patient. The trial will be conducted through a partnership between academic investigators and two health care provider organizations with different business models, cultures, and electronic data systems. Innovative approaches that are relevant and applicable across a broad range of health care systems and diseases will be used for highly centralized execution of the trial, and tools wil be developed and shared with the broader research community. Thus, in addition to efficiently testing a simple but potentially high-impact intervention for patients with kidney failure, the TiM trial demonstration project will generate important advances for conducting cost-effective, large-scale clinical trials that assess the effectiveness of interventions in real-world settings.